Method for treating obstructed paranasal sphenoid sinuses

ABSTRACT

A set of sinus balloon catheters are provided for treating a patient&#39;s paranasal sphenoid sinus system, including dilating prepared openings, and natural ostia and ducts and excising sinus cavities. These include a balloon catheter with a bend placing a distal segment at 90 degrees to a proximal segment and a balloon catheter which is substantially straight. The catheters have sufficient stiffness and column strength that the balloon carrying distal segment of the catheter can be pushed into the prepared opening, natural ostium or duct, or sinus to be excised. The catheters have appropriate inflated working diameters and appropriate outer diameters with the balloon deflated that will enable the catheter to be pushed into the respective prepared opening, natural ostium or duct, or sinus cavity to be excised. The methods use the balloon catheters to dilate prepared openings to selected parts of the sinus system, to dilate natural ostia and ducts of the sinus system, and/or to dilate sinus cavities to remove them.

PRIOR APPLICATION

This is a divisional of U.S. patent application Ser. No. 10/259,300,filed Sep. 30, 2002.

FIELD OF THE INVENTION

This invention relates to balloon catheters and methods using suchcatheters for treating paranasal sinuses.

BACKGROUND

To fully understand the invention, it is necessary to consider theanatomy and physiology of the sinus system. FIGS. 4-16, which showvarious steps of methods of the invention, also show important featuresof sinus anatomy. The maxillary sinus 21 lies lateral to the nasalcavity 38, inferior to the eye orbit 23 and superior to the palate orroof of the mouth. The medial wall of the maxillary sinus forms thelateral nasal wall 44 inferiorly. The frontal sinus 35 (FIG. 16) liesabove the orbit and its floor is formed by the frontal bone and iscontiguous with part of the orbital roof. The right and left frontalsinuses are divided by the interfrontal septum. The frontal sinus drainsinto the nasal cavity and its outflow tract is in the inferomedialsinus, which connects to the frontonasal duct 36. Frontonasal duct 36empties into the nasal cavity through lateral nasal wall 44 under themiddle turbinate 20.

The ethmoid sinus is divided into anterior and posterior ethmoid aircells 29 and 31. The ethmoid sinus consists of multiple spaces or cellsdivided by thin bony septae. The ethmoid sinus is contained in theethmoid bone. The lateral wall of the ethmoid sinus composes the medialwall of the orbit. The medial wall of the ethmoid sinus composes thelateral wall 44 of the nasal cavity superiorly. Anterior ethmoid aircells 29 drain through lateral nasal wall 44 into the middle meatus 22beneath middle turbinate 20.

The sphenoid sinus 39 is posterior to the ethmoid sinus 29 and 31.Sphenoid sinus 39 has a lateral wall that is adjacent to the opticnerve, carotid artery, and cavernous sinus. The floor of sphenoid sinus39 lies above maxillary sinus 21 and pterygopalatine fossa. Lateralnasal wall 44 is partially covered by inferior 46, middle 20, andsuperior 17 turbinates.

Sinus physiology will now be considered. The mucosa of nasal cavity 38contains secretory elements (mucosal glands and goblet cells) and adense ciliary layer. The paranasal sinuses are covered by a similarmucosa, although the secretory cells and cilia may be sparser in themore remote areas of the sinuses. The secretory cells produce a largevolume of mucus that is normally actively transported by the cilia(mucociliary transport) in a specific pattern (not a gravity dependantpattern) from the sinus through the opening between the sinus and thenasal cavity (sinus ostium). Cellular debris and bacteria aretransported in the mucus from the sinus cavity through the ostium intothe nose.

Inflammation of the sinus and nasal mucosa causes hyperemia, lymphaticswelling, stasis in the blood and lymphatic pathways and leads toincreased secretion of mucus and reduced mucociliary transport. Theinflammation may be caused by allergies, noxious agents, nasal polyps,and other factors. Over time there is a pathologic increase ininflammatory cells, ground substance, and fibers with a permanentdisruption of mucociliary transport and lymphatic drainage. Anobstruction of the narrow ducts and ostia between the paranasal sinusesand nasal cavity develops, resulting in a vicious cycle of increasedsecretions, edema, and ultimately organized connective tissue andmucosal hyperplasia. Bacteria are not cleared from the sinuses andmultiply in the fertile inflammatory environment worsening the chronicsinus inflammation (sinusitis).

Treatment with antibiotics, corticosteroids in nasal sprays orsystemically, and antihistamines may result in resolution of sinusitis.However some patients become resistant to medical treatment and surgerybecomes necessary.

Modern sinus surgery is usually performed endoscopically and is based onthe principle of restoring patency of the sinus ducts and ostia byenlarging the opening and allowing mucociliay clearance of mucus fromthe sinus into the nose to resume. If mucociliary clearance isre-established, then the inflammatory changes in the sinus mucosadescribed above will resolve. In classic sinus surgery, an incision wasmade along the side of the nose in the medial canthus to access theethmoid or sphenoid sinuses. This incision could be extended to beneaththe medial half of the brow to also access the frontal sinus. Anincision through the gums above the upper teeth and creation of a largebony opening in the maxilla with excision of large areas of sinus mucosawas used to perform maxillary sinus surgery. A large opening was createdthrough the medial wall of the maxillary sinus into the nose in theinferior meatus (maxillary antrostomy) to allow postoperative drainageof the sinus.

The development of endoscopic sinus surgery allowed sinus surgery to beperformed from an intranasal approach, thus eliminating the need forexternal incisions, the creation of very large bony openings, andreducing morbidity. However, endoscopic sinus surgery requires theexcision of large areas of bone and nasal mucosa and has reportedcomplications of blindness from damage to the optic nerve, double visionfrom damage to the orbit and medial rectus muscle, damage to thenasolacrimal duct resulting in tearing and dacryocstitis, leakage ofcentral nervous system fluid and infection of the brain and meninges,loss of the sense of taste, and pain and neuralgia of the face andscalp, and infection of the skull base.

As shown in U.S. Pat. Nos. 5,021,043 and 5,169,386, I have previouslyco-invented balloon catheters for use in the lacrimal system. In myapplication “Transnasal Method and Catheter for Lacrimal System,” filedherewith, I teach that a balloon catheter can be introduced transnasallyto treat the lacrimal system.

A review of the prior art shows a number of patents (Katz U.S. Pat. No.6,027,478; Brennan U.S. Pat. No. 4,883,465; Akiyama U.S. Pat. No.4,102,342; Payton U.S. Pat. No. 4,338,941; Katz U.S. Pat. No. 5,454,817;Stangerup U.S. Pat. No. 5,546,964 and Shippert U.S. Pat. No. 5,827,224)which teach the use of expandable devices (usually a balloon) into thenasal cavity or sinuses. Most of these are for the treatment of nosebleeds or the control of bleeding.

A number of articles disclose the use of a balloon catheter in sinusesto hold fractured bones in place, stop bleeding by tamponade, preventfluid from flowing out of the nose into the pharynx, or to maintain alow intranasal air pressure. In one case, a catheter was used to stent aduct after surgery; and the balloon was inflated in the sinus to deepthe stent in position. However, there are no teachings in the prior areto use a balloon catheter to create a new opening from a sinus into thenose, to dilate an ostium or duct, or excise a sinus. A balloon wasnever used to directly treat sinus disease.

SUMMARY

The present inventions teaches the use of sinus balloon catheters totreat sinus disease by creating a new opening from a sinus into thenose, to dilate a sinus ostium or duct, or to excise a sinus. Theballoon catheters of the invention constitute a set of catheters havingdifferent configurations and dimensions suitable for the treatment ofdifferent parts of the paranasal sinus system. The catheters comprise ahypotube formed of stainless steel of sufficient stiffness and columnstrength to act as a pushable member to be pushed through a surgicallyprepared small, tight opening from a sinus into the nose, through asinus ostium or duct, or into a sinus cavity. The small opening may becreated surgically or may be the natural ostium or duct of the sinus. Inother words, the balloon acts as an expandable and contractable memberwhich in a smaller, contracted or deflated profile can be pushed into aspace in the patient's sinus and then expanded to a larger, expanded orinflated profile. After waiting a period, the expandable andcontractable member can be contracted or deflated and removed to dilatethe space.

One of the balloon catheters used in the invention has a proximalsegment and a circular bend placing a distal segment at an angle of 70degrees to 115 degrees, preferably 90 degrees to the proximal segment. Aballoon is mounted over the distal segment which has a slot permitting afluid under the pressure applied to the proximal end of the proximalsegment to inflate the balloon. In other words, the tube acts as a fluidsupply conduit in fluid communication with the balloon.

The angled distal segment allows the surgeon to rotate or shift theposition of the long proximal catheter shaft, thus positioning thedistal segment to enter from the nasal cavity into the sinus at variousangles appropriate to each individual patient. The balloon catheter withthe 90 degree angle is used to treat maxillary and frontal sinusdisease.

The distal segment of the balloon catheter from the outside of the bendto the end of the catheter is 14 mm. The length of the distal segment isshort enough to allow it to be rotated within the nasal cavity and thusenter from the nasal cavity into the sinus at the desired angle. Thedistal segment is long enough to allow a balloon of sufficient lengthand diameter to be attached to the hypotube for dilation of an openingthrough the lateral nasal and sinus wall, duct, or ostium. The balloonmaterial is attached with adhesive to the very distal portion of thedistal segment and to the proximal portion of the distal segment, thebend, and the very distal portion of the long proximal segment. A longerworking segment of balloon can be used because the area of adhesion ofthe balloon includes the bend and the distal portion of the proximalsegment. A 9 mm inflated diameter angled balloon is used to treat themaxillary sinus and a 5 mm inflated diameter angled balloon is to treatthe frontal sinus.

Another balloon catheter of the invention is straight or has a minimalangle at the junction of the distal segment and the proximal segment.This balloon catheter is used for ethmoidectomy and sphenoid sinusotomyand uses a balloon with an inflated diameter of 9 mm. Each of theballoon catheters of the invention have a sufficiently small deflatedprofile to fit through the sinus ostium, duct, or opening in the nasalwall or scar tissue into the sinus.

It is useful to apply a lubricious coating to the balloon material tofacilitate pushing it through the lateral nasal wall and sinus wall intothe sinus. The proximal catheter shaft has a luer lock with wings or anexpansion to allow the catheter to be attached to tubing from theinflation device. The wings allow the surgeon to more easily manipulatethe balloon catheter.

The methods of the invention open or enlarge an obstructed or narrowedostium or duct of a sinus using a balloon and allow the sinus to draininto the nose. This is accomplished without causing damage to thesurrounding structures such as the optic nerve, extraocular muscles thatmove the eye, the orbit, brain, meninges, or nasolacrimal duct.

Another method of the invention removes a sinus and cures sinus diseasewithout damage to the surrounding structures such as the optic nerve,extraocular muscles, orbit, brain, meninges, and nasolacrimal duct. Themethods of the invention are useful for opening a sinus ostium or ductwhich has been narrowed or obstructed by scar tissue from previoussurgery or trauma, for creating a new opening in the wall of a sinuswhich has scar tissue to allow proper drainage of the sinus into thenose, and for removing a sinus which has scar tissue.

The methods of the invention include a balloon catheter antrostomy ofthe maxillary ostium, a balloon catheter middle meatal maxillaryantrostomy, a balloon catheter inferior meatal antrostomy, a ballooncatheter ethmoidectomy of the anterior ethmoid sinus, a balloon catheterethmoidectomy of the posterior ethmoid sinus, a balloon cathetersinusotomy of the sphenoid sinus, and a balloon catheter frontalsinusotomy.

BRIEF DESCRIPTION OF THE DRAWING

FIG. 1 is a schematic drawing of one embodiment of the sinus ballooncatheter of the invention;

FIG. 2 is a closeup schematic drawing of the tip of the distal segmentof the sinus balloon catheter of FIG. 1;

FIG. 3 is a schematic drawing of a second embodiment of a sinus ballooncatheter of the invention;

FIG. 3 a is a closeup schematic drawing of the tip of the sinus ballooncatheter of FIG. 3;

FIG. 4 is a schematic drawing of a step of a method of the invention,showing the uncinate process being removed with a punch to expose theethmoid infundibulum and semilunar hiatus;

FIG. 5 is a schematic drawing of another step of the method of FIG. 4showing the sinus balloon catheter dilating and thereby enlarging theostium of the maxillary sinus;

FIG. 6 is a schematic drawing of a step of a second method of theinvention showing the Blakesely punch creating a small opening in thefontanelle of the lateral nasal wall in the middle meatus thus creatinga communication between the maxillary sinus and nasal cavity;

FIG. 7 is a schematic drawing of another step of the method of FIG. 6showing the sinus balloon catheter dilating the opening in thefontanelle of the lateral nasal wall in the middle meatus thus creatinga large communication opening (antrostomy) for drainage from themaxillary sinus into the nasal cavity;

FIG. 8 is a schematic drawing of a step of a third method of theinvention showing the dissector perforating the lateral nasal wall inthe inferior meatus into the maxillary sinus;

FIG. 9 is a schematic drawing of another step of the method of FIG. 8showing the sinus balloon catheter dilating the opening in the lateralnasal wall in the inferior meatus thus creating a large antrostomy fordrainage from the maxillary sinus into the nasal cavity;

FIG. 10 is a schematic view of a fourth method of the invention showingthe cutting forceps making a new opening in the anterior wall of theethmoid bulla;

FIG. 11 is a schematic view of another step of the method of FIG. 10showing the straight sinus balloon catheter dilating the ethmoid bulla;

FIG. 12 is a schematic view of yet another step of the method of FIG. 10showing the straight sinus balloon catheter dilating the ethmoid aircells and thus completing the anterior ethmoidectomy;

FIG. 13 is a schematic view of yet another step of the method of FIG. 10showing a punch perforating the basal lamella of the middle turbinate;

FIG. 14 is a schematic view of still another step of the method of FIG.10 showing the straight sinus balloon catheter dilating the posteriorethmoid air cells and thus completing the posterior ethmoidectomy;

FIG. 15 is a schematic view of an additional step of the method of FIG.10 showing the sinus balloon catheter dilating the anterior wall of thesphenoid sinus;

FIG. 16 if a schematic view of a further step of the method of FIG. 10showing the angled sinus balloon catheter dilating the frontonasal duct.

DESCRIPTION OF THE PREFERRED EMBODIMENT(S)

As shown in FIGS. 1 and 2, a first embodiment of a sinus ballooncatheter 130 of the invention is assembled from a tube 136, preferably astainless steel hard tempered hypotube which has a circular bend 138 of0.13 inch radius such that distal segment 137 is oriented 70 degrees to115 degrees, preferably 90 degrees, to proximal segment 139. A slot 140is provided in segment 137. The distance from the distal tip 184 ofdistal segment 137 to the outer wall of proximal segment 139 of hypotube136 is 4 mm to 30 mm, preferably 14 mm, as shown in FIG. 1. The distaltip 184 of the hypotube 136 is closed, whereas the proximal end 142 isopen. However, the lumen of tube 136 may be closed in distal segment137, up to 10 mm from distal tip 184, allowing distal tip 184 to remainopen. In either case, tube 136 is closed distally of slot 140. Theproximal end 142 of hypotube 136 is inserted into a mold for formingluer 144 and plastic is injected into the mold to form luer 144 attachedto the end of proximal segment 139. The inner diameter of the luer 144matches the external diameter of the hypotube 136. The luer 144 haswings 143 or other enlargement or expansion on it to enable the surgeonto better hold and manipulate balloon catheter 130. Catheter 130 is 4inches to 10 inches long, preferable 6 inches in length as measured fromproximal end 142 to distal tip 184, as shown in FIG. 1. The wall 132 oftube 136 should be of such thickness that the tube has sufficientstiffness and column strength with marked resistance to lateral bendingthat distal segment 137 can be pushed through a prepared small, tightopening from a sinus into the nose, pushed through a sinus ostium orduct, or pushed into a sinus cavity which may require considerablepressure in some cases. It has been found that a tube with a wallthickness of at least 0.035 inch will be satisfactory. A preferred tubehas an outer diameter of 0.083 inch and an inner diameter of 0.039 inchwith a wall thickness of 0.044 inch.

Port 140 in distal segment 137 is formed by inserting temporarily adiscardable wire segment into the tube 136. This is done beforeinserting hypotube 136 into luer 144. A transverse slot is cut in thetube 136 approximately 2 mm to 14 mm, preferably 4 mm, from its distalend 184 to form port 140. The slot extends in depth to approximately onethird of the diameter of tube 136. A wire wheel is used to remove anyburrs, and the discardable core wire is removed and discarded.

A balloon 134 is preferably formed of polyethylene terephthalate and hasa length of approximately 4 mm to 30 mm, preferably 14 mm, and a workinginflated diameter of 2 mm to 14 mm, preferably 9 mm, for use in thesinus system, except for use in the nasofrontal duct where thepreferable inflated working diameter is 5 mm. The balloon has a distalneck 170, a distal tapered region 172, a center region 174, a proximaltapered region 176, and a proximal neck 178. During installation, tube136 is cleaned with isoproponol and then coated with a primer, “Loctite770.” The balloon is placed over the distal end of tube 136 to align thedistal end of distal neck 170 with distal end 184 of tube 136. Anadhesive, such as cyanoacrylate, is used. An acceptable adhesive“Loctite 4081” is available from Loctite Corporation. The adhesive isapplied to distal end of distal neck 170 and the proximal end ofproximal neck 178 to form bonds 180 and 182, respectively. The adhesiveis applied to the balloon necks 170, 178 using a small mandrel such as awire approximately 0.010 inch to 0.014 inch in diameter. The adhesivewicks into the necks due to capillary action. Proximal neck 178 may bebonded on distal segment 137 of tube 136 or extend over bend 138 ontothe distal end portion of proximal segment 139 of tube 136. Extension ofthe proximal neck 178 onto bend 138 and proximal segment 139 allows agreater length of the working diameter, i.e., center region 174, to beon distal segment 137 of tube 136.

A second embodiment of sinus catheter of the invention is shown in FIG.3. The catheter 230 is assembled from a tubular body 232, formed ofstainless steel hard tempered hypotube 236 which is straight or has amild circular bend distally such that distal segment 237 is oriented 130to 180, preferably 180 degrees, to a long proximal segment 239. Thedistance from the distal tip 284 of distal segment 237 to the outer wallof proximal segment 239 of hypotube 236 is 10 to 100 mm, preferably 16mm. The distal tip 284 of the hypotube 236 preferably is closed whereasthe proximal end 242 is open. However, the lumen of tube 236 may beclosed 0 to 10 mm from distal tip 284 allowing distal tip 284 to beopen. The proximal end 242 of hypotube 236 is inserted into a mold forforming luer 244. Heated plastic is injected into the mold to form luer244 attached to the end of proximal segment 239. The inner diameter ofluer 244 matches the external diameter of hypotube 236. The luer 244 haswings 243 or expansions on it to enable the surgeon to better hold andmanipulate balloon catheter 230.

Catheter 230 has a port 240 in distal segment 237 which is formed byinserting temporarily a discardable wire segment into the tube 236. Thisis done before inserting hypotube 236 into luer 244. A transverse slotis cut in tube 236 approximately 2 to 14 mm, preferably 4 mm, from itsdistal end 284 to form port 240. The slot extends in depth toapproximately ⅓ of the diameter of tube 236. A wire wheel is used toremove any burrs, and the discardable core wire is removed anddiscarded.

It is desirable for the catheter 230 to have column strength and markedresistance to lateral bending. The deflated catheter must be capable ofbeing pushed through an initial prepared small opening in the nasal orsinus wall, an ostium or duct, and into a sinus cavity. This may requireconsiderable pressure in some cases.

A balloon 234, preferably formed of polyethylene terephthalate, has alength of approximately 4 to 30 mm, preferably 14 mm, and an inflatedworking diameter of 3 to 15 mm, preferably 9 mm. The balloon has adistal neck 270, a distal tapered region 272, a center region 274, aproximal tapered region 276, and a proximal neck 278. Necks 270 and 278are bonded to hypotube 236, forming bonds 280 and 282, in the samemanner as is described above with respect to the attachment of necks 178and 170 to hypotube 136.

As will be described below, angled catheter 130 and “straight” catheter230 will be used in different method steps for treating various preparedopenings, naturally occurring ostia and ducts, and sinus cavities. It isalso to be noted that dimensions of the catheters are selected toaccommodate different conditions in the paranasal sinus system. Forexample, the outer diameters of the distal segments with the balloondeflated are selected so that the respective distal segments with theballoon deflated will fit snugly with the prepared openings, naturalostia or ducts and sinus cavities into which these distal segments areto be pushed. As already mentioned, the working inflated diameters ofthe balloons differ depending on the size required to treat differentparts of the paranasal sinus system. Accordingly, the surgeon must, atthe time surgery is begun, have available a set of sinus ballooncatheters which are angled or straight, the balloons of which haveappropriate inflated working diameters, and which have appropriate outerdiameters with the balloon deflated that will enable the catheter inquestion to be pushed into the respective prepared opening, naturalostium or duct or sinus cavity to be excised.

Turning to FIGS. 4 and 5, in a method of performing balloon catheterantrostomy of the maxillary ostium, the middle turbinate 20 is retractedmedially to gain access to the middle meatus 22. In some cases themiddle turbinate is resected. The ethmoid infundibulum 24 is exposed byusing cutting forceps 67 to remove part of the uncinate process 26 (FIG.4). Distal segment 137 of balloon catheter 130 is then pushed throughthe maxillary ostium 41 (which is in ethmoid infundibulum 24) into themaxillary sinus 21. As seen in FIG. 5, balloon 134 is inflated to 9 bars(atmospheres) for 20 seconds then deflated. Distal segment 137 ofballoon catheter 130 is slightly repositioned to insure full dilationand inflated again to 9 bars for 20 seconds. Balloon 134 is thendeflated, and catheter 130 is removed from the now enlarged ostium 41.

Turning to FIGS. 6 and 7, in a method of performing a middle meatalmaxillary antrostomy, an initial opening is made in the fontanelle 40(section of thin membranous tissue without bone of the medial maxillarysinus wall 42 which is also a portion of the lateral nasal wall 44).This is performed by bringing a 45 degree upbiting Blakesely punch 60into nasal cavity 38 along the lateral nasal wall 44 just superior tothe inferior turbinate 46 at the midpoint of its horizontal axis toperforate fontanelle 40 to create a new 3 mm opening 50 (FIG. 6). Thepunch 60 is removed, and sinus balloon catheter 130 is brought intonasal cavity 38 and pushed into the new opening 50 in fontanelle 40 oflateral nasal wall 44 (FIG. 7). Balloon 134 is inflated to 9 bars for 20seconds then deflated. Balloon catheter 130 is slightly repositioned inthe enlarged opening 50 to insure thorough dilation and inflated againto 9 bars for 20 seconds. Balloon catheter 130 is then deflated andwithdrawn from opening 50 and nasal cavity 38.

As seen in FIGS. 8 and 9, in a method of inferior meatal antrostomy, theinferior turbinate 46 has been displaced medially. A sharp dissector 64is introduced into nasal cavity 38 and used to perforate lateral nasalwall 44 in the inferior meatus 52 to create an opening 56 in lateralnasal wall 44 (FIG. 8). Dissector 64 is withdrawn from nasal cavity 38.The deflated balloon catheter 130 is introduced into the nasal cavity38, and distal segment 137 of balloon catheter 130 is pushed throughopening 56 in lateral nasal wall 44. The balloon 134 is inflated to 9bars for 20 seconds then deflated. Deflated balloon 134 is slightlyrepositioned to assure total dilation of the opening 56. A seconddilation of the balloon 134 to a pressure of 9 bars for 20 seconds isperformed. The balloon catheter 130 is then deflated and withdrawn fromopening 56 and nasal cavity 38.

A balloon catheter ethmoidectomy of the anterior ethmoid sinus is shownin FIGS. 10-12. The middle turbinate 20 (FIG. 5) has been retractedmedially to gain access to the middle meatus 22 (FIG. 5). In some cases,the middle turbinate may be partially or totally removed. The ethmoidinfundibulum 24 is exposed by removing part of the uncinate process 26(FIG. 4). A fine cutting forceps 66 is used to remove the anterior wall30 of the ethmoid bulla 28 (FIG. 10). After anterior wall 30 of ethmoidbulla 28 is removed, the straight balloon catheter 230 is brought intonasal cavity 38, and distal segment 237 is pushed into bulla 28 (FIG.11). Balloon 234 is inflated to 9 bars for 20 seconds then deflated.Balloon catheter 230 is then withdrawn from bulla 28. Distal segment 237of balloon catheter 230 is then pushed into the anterior ethmoid aircells 29 which lie posterior to the previously removed ethmoid bulla 28(FIG. 12). Balloon 234 is inflated to 9 bars for 20 seconds thendeflated. Balloon catheter 230 is then slightly repositioned to insurethorough dilation and inflated again to 9 bars for 20 seconds, deflated,and removed from the area of anterior ethmoid cells 29.

FIGS. 13 and 14 illustrate an ethmoidectomy of the posterior ethmoidsinus. When the posterior ethmoid sinus cells 31 must be removed, thebasal lamella 32 of the middle turbinate 20 is perforated with a punch68 (FIG. 13). Distal segment 237 of balloon catheter 230 is then pushedthrough the new opening 34 in the basal lamella 32 of the middleturbinate 20 into the posterior ethmoid air cells 31 and inflated 9 barsfor 20 seconds (FIG. 14). Balloon catheter 230 is then deflated,slightly repositioned, and again inflated 9 bars for 20 seconds. Ballooncatheter 230 is then deflated and withdrawn.

FIG. 15 shows sinusotomy of the sphenoid sinus. After anterior andposterior ethmoidectomy, distal segment 237 of balloon catheter 230 isinserted through the anterior wall 37 of sphenoid sinus 39 (FIG. 15).The balloon 234 is then inflated to 9 bars for 20 seconds then deflated.The balloon catheter 230 is slightly repositioned to insure thoroughdilation and inflated again to 9 bars for 20 seconds, then deflated, andwithdrawn.

FIG. 16 illustrates sinusotomy of the frontal sinus. After an anteriorethmoidectomy the nasofrontal duct 36 is exposed and in the surgeon'sview. The distal segment 137 of an angled catheter 130 with a 5 mminflated working diameter is brought into the frontnasal duct 36 andinflated to 9 bars, then deflated. The distal segment 137 of the ballooncatheter 130 is slightly repositioned to insure complete dilation of thenasofrontal duct 36 and inflated to 9 bars for 20 seconds then deflatedand withdrawn.

All of the above procedures may be performed in a similar fashion inpatients who have had previous sinus surgery and the sinus openings havebeen obstructed by scar tissue or granulation tissue.

1. A method of treating a patient's sphenoid sinus having an obstructedor narrowed sphenoid ostium, the method comprising: pushing a distalsegment of a balloon catheter through the obstructed or narrowedsphenoid ostium; and, inflating a balloon of the balloon catheter in theobstructed or narrowed sphenoid ostium.
 2. The method of claim 1,wherein the obstructed or narrowed sphenoid ostium is naturallyoccurring and does not have scar tissue.
 3. The method of claim 1,further comprising: shifting a proximal segment of the balloon catheterto position the distal segment to enter from the patient's nasal cavityinto the sphenoid ostium.
 4. The method of claim 1, further comprising:rotating a proximal segment of the balloon catheter to position thedistal segment to enter from the patient's nasal cavity into thesphenoid ostium.
 5. The method of claim 1, wherein the balloon catheterhas sufficient stiffness and column strength that the distal segment canbe pushed through the sphenoid ostium.
 6. The method of claim 1, whereinthe distal segment of the balloon catheter is at an angle of betweenabout one hundred thirty degrees and about one hundred eighty degrees toa proximal segment of the balloon catheter.
 7. The method of claim 6,wherein the angle is about one hundred eighty degrees.
 8. The method ofclaim 1, further comprising: selecting the balloon catheter such thatthe distal segment, when the balloon is deflated, will fit snugly withthe obstructed or narrowed sphenoid ostium.
 9. The method of claim 1,further comprising: medially retracting the patient's middle turbinate.10. The method of claim 1, further comprising: removing part of thepatient's uncinate process.
 11. The method of claim 1, furthercomprising: performing an ethmoidectomy.
 12. The method of claim 1,further comprising: inflating the balloon to about nine atmospheres. 13.The method of claim 1, further comprising: deflating the balloon;repositioning the balloon after the deflating; and, inflating theballoon after the repositioning.